(Reuters Health) - Elementary school children with cleft lip, cleft palate and other facial anomalies may struggle more than older kids with anger, anxiety, depression and stress, according to a recent study.

Compared to older kids and teens, those between ages 8 and 10 have the highest risk for psychosocial dysfunction, the study team reports in Plastic and Reconstructive Surgery.

“The ultimate goal for all of us who work in craniofacial surgery is to help kids feel better and grow up normally,” said senior author Dr. Justine Lee of the University of California, Los Angeles David Geffen School of Medicine.

“At first, we weren’t looking for differences in age but other factors such as health insurance, socioeconomic status or how many surgeries they had over time,” she told Reuters Health in a telephone interview. “It surprised us to find out how tough elementary school was, realizing somebody else is different and noticing your own differences.”

The researchers surveyed 99 patients at the UCLA Craniofacial Clinic ranging in age from 8 to 17 years. The survey asked the girls and boys to recall how they felt in the past week, including anger, anxiety and depression, as well as how social interactions made them feel.

When researchers split participants into groups aged 8-10, 11-13 and 14-17, they found that the 8-10 age group showed the highest anxiety and depression and had the lowest peer-relationship scores overall.

The youngest age group also had the most severely affected children. In particular, 30 percent of those between ages 8 and 10 had severe anxiety scores and 37 percent had severely low peer relationship scores. The 11-13 age group had the lowest anger scores.

“Some surgeons like to wait before doing certain reconstructive surgeries, but it’s good to know that we need to be more aware of the appearance concerns in the 8-10 age range,” said Dr. Russell Reid, director of the cleft and craniofacial services program at the University of Chicago Medical Center, who wasn’t involved in the study.

“We’ve assumed that teens were more aware of their surroundings and self-perception, but we need to be sensitive to issues that affect our elementary-age patients and their daily living,” Reid said in a telephone interview.

Lee and colleagues are working on several follow-up studies regarding psychosocial stress in children with facial birth defects and finding that parents believe high school is a more fragile time than elementary school.

The research team is also working with children and parents who speak Spanish in the Los Angeles area.

“For some reason, those children are doing worse,” Lee said. “We’re not sure if it’s the general immigrant experience or a particular effect of craniofacial anomalies.”

Reid said that he and colleagues plan to begin using the survey from this study to understand patients’ stress in the Chicago area, looking at the “before” and “after” effects of surgery on anxiety, depression and anger.

“We also want to follow our patients as they get older and begin to function in society,” Reid said. “Not only peer outcomes but how they feel as they integrate into society, jobs and their careers.”

Craniofacial surgery often means more to the patient than a physical change, he added. “It’s not only about fixing a structure; it’s about taking care of the whole child.”

Similarly, parents should remain aware of how their children perceive themselves and feel about their social status, Lee added.

“Kids go through a lot of things growing up, and anomalies add another stress on top of that,” she said. “It’s important for everyone to celebrate and be proud of their differences, no matter what it is.”

All parents can be supportive, whether or not their children have facial anomalies, Lee said.

“Words and actions can be hurtful and have long-lasting impacts. Be careful and aware and take that additional step of consideration.”